Clinical Performance of Self-collected Specimen HPV-DNA vs Clinician- collected Specimen HPV-mRNA to Detect High-risk HPV and High-grade Cervical Lesions and Cancer.

OBJECTIVE: Self- collected specimens to detect high-risk (hr) HPV and high-grade cervical lesions (CIN2+) has been introduced aiming to increase cervical cancer screening coverage. The performance of self- collected specimen  compared to clinician collected specimen is one major concern. This study aimed to compare self-sampling HPV-DNA and clinician-sampling HPV-mRNA to detect hr-HPV and high-grade cervical lesions. METHODS: Women with abnormal cervical cytology and/ or positive hr-HPV who attended the colposcopy clinics in 10 tertiary hospitals in Bangkok were enrolled. Self-collected specimens were evaluated for  HPV DNA using Cobas® 4800 HPV test prior to the clinician-collected specimens which were tested for HPV mRNA with APTIMA® HPV Assay. Subsequent colposcopy with biopsy was performed. The detection rates of hr-HPV from both HPV tests and their performance to detect high-grade lesions pathology were compared. RESULTS: Data from 497 women's specimens were analyzed. Both samplings had 86.8% concordance rate in detecting hr-HPV (Kappa 0.670; 95% confidence interval [CI] 0.599-0.746, P value < 0.001). The sensitivity (95% CI) of self-collected specimen HPV DNA and clinician- collected specimen HPV-mRNA to detect high-grade lesions were 91.8% (85.4%-96.0%) and 90.2% (83.6%-94.9%) respectively. The corresponding negative predictive values (95% CI) were 91.9% (85.6%-96.0%) and 91.7% (86.0%-95.7%) respectively. CONCLUSION: HPV DNA testing from self-collected specimen to detect HR-HPV demonstrates high concordance with HPV mRNA testing from clinician-collected specimen. The sensitivity and negative predictive value of both tests to detect high-grade lesions are comparable.

The role of random cervical biopsies in addition to colposcopy-directed biopsies in detection of CIN2.

The aim of this study was to determine the additional values of multiple cervical biopsies when any colposcopy was performed. We developed a cross-sectional study of 92 women, who had been referred for a colposcopy because of their abnormal cervical cytology. Colposcopy-directed biopsies were taken from lesions and random non-directed biopsies were added, if their directed biopsies were fewer than four in number. The biopsy sites were ranked according to the impression of the clinicians. Among the 92 women, the first biopsy was normal in 29.4%, revealing CIN1 in 28.3% and CIN2+ in 42.3%. In the second and third biopsies, the CIN2+ was found to have increased to 35.8% and 36.8%, respectively. The accumulative sensitivity for detecting CIN2+ was 84.8%, for a single biopsy. This increased to 97.0%, after two biopsies and then to 100%, after three and four biopsies. To conclude, although the taking of the additional biopsies increased the CIN2+ detection, collecting three cervical biopsies might be sufficient. Impact Statement What is already known on this subject? The colposcopy is considered to be the standard procedure in the detection of precancerous lesions of the cervix. However, nowadays, colposcopic biopsy practices do not have any single, acceptable guideline for the number of biopsies performed, and whilst a single biopsy is the most commonly adopted practice, some centres have used a biopsy protocol with multiple biopsies. What the results of this study add? This study determined the rate of the detection of CIN2+ by using multiple biopsy protocols during colposcopy for women who were referred with their abnormal cervical cytology. We explored the benefit of collecting additional lesion-directed biopsies and additional biopsies of a normal-appearing cervix in addition to a single biopsy. We found that two or three biopsies from a colposcopy should be enough for increasing the detection of CIN2+. Also, multiple biopsies increased the sensitivity of CIN2+ detection, especially in colposcopic impression for the low grade lesions. What the implications are of these findings for clinical practice and/or further research? We suggest that colposcopy-directed biopsies should be supplied by one or two random biopsies from other quadrants of the cervix.

Prevalence and Associated Factors of Abnormal Cervical Cytology and HighRisk HPV DNA among Bangkok Metropolitan Women.

BACKGROUND: Many strategies are required for cervical cancer reduction e.g. provision of education cautious sexual behavior, HPV vaccination, and early detection of preinvasive cervical lesions and invasive cancer. Basic health data for cervical cytology/ HPV DNA and associated factors are important to make an appropriate policy to fight against cervical cancer. AIMS: To assess the prevalence of abnormal cervical cytology and/or HPV DNA and associated factors, including sexual behavior, among Bangkok Metropolitan women. MATERIALS AND METHODS: Thai women, aged 25to65 years old, had lived in Bangkok for ≥5 years were invited into the study. Liquidbased cervical cytology and HPV DNA tests were performed. Personal data were collected. MAIN OUTCOMES MEASURES: Rates of abnormal cytology and/ or highrisk HPV (HRHPV) and factors associated with abnormal test(s) were studied. RESULTS: Abnormal cytology and positive HRHPV were found in 6.3% (279/4442 women) and 6.7% (295/4428), respectively. The most common abnormal cytology was ASCUS (3.5%) while the most common HRHPV genotype was HPV 16 (1.4%) followed by HPV 52 (1.0%), HPV 58 (0.9%), and HPV 18 and HPV 51 at equal frequency (0.7%). Both tests were abnormal in 1.6% (71/4428 women). Rates of HRHPV detection were directly associated with severity of abnormal cytology: 5.4% among normal cytology and 13.0%, 30.8%, 40.0%, 39.5%, 56.3% and 100.0% among ASCUS, ASCH, AGCNOS, LSIL, HSIL, and SCC, respectively. Some 5% of women who had no HRHPV had abnormal cytology, in which 0.3% had ≥ HSIL. Factors associated with abnormal cytology or HRHPV were: age ≤40 years, education lower than (for cytology) or higher than bachelor for HRHPV), history of sexual intercourse, and sexual partners ≥2. CONCLUSIONS: Rates for abnormal cytology and HRHPV detection were 6.3% and 6.7% HRHPV detection was directly associated with severity of abnormal cytology. Significant associated factors were age ≤40 years, lower education, history of sexual intercourse, and sexual partners ≥2.

Knowledge and Attitudes of Bangkok Metropolitan Women towards HPV and Self-Sampled HPV Testing.

BACKGROUND: To evaluate knowledge of Bangkok women regarding HPV and self-sampled HPV testing, and their attitudes towards testing. MATERIALS AND METHODS: Thai women who had lived in Bangkok for more than 5 years, aged 25-to-65 years old, were invited to join the study. Participating women were asked to a complete self-questionnaire (Thai language), with literate assistance as needed. The questionnaire was divided into 3 parts: (I) demographic data, (II) knowledge and (III) attitudes towards self-sampled HPV testing. Before proceeding to Part III of the questionnaire, a 15-minute educational video of self-sampled HPV testing was presented to all participants. RESULTS: Among 2,810 women who answered the questionnaires, 33.7% reported that they did not know about HPV. The characteristic features of these women were older age (>50 years), lower income (<600 USD/month), unemployed status, and non-attendees at cervical cancer screening. Only small numbers of women (4.6%) responded that they had heard about self-sampled HPV testing. After having information, 59.6% would not use the self-sampled HPV testing as a method of cervical cancer screening (non-acceptance). Factors significantly associated with the non-acceptance were older age, lower income, having no knowledge about HPV or self-collected HPV testing, a perception that the testing was unreliable and a concern that they might not be able to perform it correctly. CONCLUSIONS: Nearly half and almost all Bangkok women did not know about HPV and self-sampled HPV testing, respectively. Approximately 60% of Bangkok women refused to do the self-sampled HPV testing. Significant negative attitudes were concerns that the testing would be unreliable and a lack of confidence to perform the procedure correctly. Education about HPV and self-sampled HPV testing, ease of the procedure, or the testing models may increase rate of acceptability or positive attitudes.

Uterine Sarcoma: Clinical Presentation, Treatment and Survival Outcomes in Thailand.

BACKGROUND: Uterine sarcoma is a group of rare gynecologic tumors with various natures, and different lines of treatment. Most have a poor treatment outcome. This study targeted clinical characteristics, treatment, overall survival (OS), progression-free survival (PFS), and prognostic factors in uterine sarcoma patients in one tertiary center for cancer care. MATERIALS AND METHODS: Uterine sarcoma patients who were treated at the Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital between January 1994 and December 2014 were identified. Clinico-pathological data were analyzed. Prognostic outcomes were examined by Kaplan-Meier curves and Cox regression analysis. RESULTS: We identified 46 uterine sarcoma patients: 25 carcinosarcoma (CS) (54.3%), 15 leiomyosarcoma (LMS) (32.6%), and 6 undifferentiated uterine sarcoma (UUS) (13.1%) cases. Mean age was 54.0±11.9 years (range 25-82 years). Abnormal uterine bleeding was the most common presenting symptom (63.0%). Among 33 patients (71.7%) who had pre-operative tissue collected, diagnosis of malignancy was correct in 29 (87.9%). All patients received primary surgery and retroperitoneal lymph nodes were resected in 34 (73.9%). After surgery, 5 (10.9%) had gross residual tumors. Stage I disease was most commonly found (56.5%). Adjuvant treatment was given to 27 (58.7%), most commonly chemotherapy. After a median follow-up of 16.0 months (range 0.8-187.4 months), recurrence was encountered in 22 patients (47.8%). Median time to recurrence was 5.8 months (range1.0-105.5 months). Distant metastasis was more common than local or loco- regional failure. The 2-year PFS was 45.2% (95% confidence interval [CI], 30.6%-59.7%) and the 2-year OS was 48.3% (95% CI, 33.3%-60.7%). Multivariable analyses found residual disease after surgery as a significant factor only for PFS. CONCLUSIONS: Uterine sarcoma is a rare tumor entity. Even with multimodalities of treatment, the prognosis is still poor. Successful cytoreductive surgery is a key factor for a good survival outcome.

Knowledge, Attitudes and Behavior of Bangkok Metropolitan Women Regarding Cervical Cancer Screening.

PURPOSE: To assess knowledge, attitudes and cervical cancer screening behavior of Bangkok Metropolitan women. MATERIALS AND METHODS: Thai women, aged 25-to-65 years old, having lived in Bangkok for 5 years or more were invited to participate in the study. After signing informed consent, all women were asked to complete a self-questionnaire (Thai language) with literate assistance if needed. The questionnaire was divided into 3 parts: (I) demographic data; (II) knowledge about cervical cancer screening; and (III) behavior and attitudes, towards cervical cancer screening. Adequate screening was defined as women who had ≥two cervical cancer screening tests except women aged 25-30 years who may have only one screening, and the last screen was within 5 year or had had regular screening. RESULTS: Of 4,339 women, there were 1,857 (42.8%) with adequate screening and 2,482 (57.2%) with inadequate screening. Significant factors associated with inadequate screening included age < 45 years, pre-menopausal status, family monthly income <625 USD, no reported sexual intercourse, nulliparous, no knowledge, lack of awareness and poor attitudes. Three major reasons provided by women for inadequate screening were no symptoms (54.4%), fear of pain (33.2%), and embarrassment (34.6%). CONCLUSIONS: Personal features, knowledge, and attitudes influence screening behavior of Bangkok Metropolitan women. The three most common reasons of women for not undergoinging screening are no symptoms, fear of pain, and embarrassment. These factors should be the focus of attention to improve coverage of cervical cancer screening in Bangkok.

Other Gynecologic Pathology in Endometrial Cancer Patients.

BACKGROUND: To evaluate the prevalence and features of other gynecologic or surgical lesions in endometrial cancer (EMC) patients. MATERIALS AND METHODS: Clinico-pathological data of EMC patients who were treated in the institution from 1995 to 2012 were collected. Data collected were age, stage of disease according to the FIGO 2009 criteria (FIGO), histopathology, tumor grade, adjuvant therapy, other gynecologic or surgical lesions, follow-up period, and living status. RESULTS: The mean age of 396 patients was 56.7 ± 10.64 years. Abnormal uterine bleeding was the most common presenting symptom (90.1%). Bleeding was accompanied with pelvic mass in 7.7% and 5.4% had only a pelvic mass. Abnormal cervical cytology was found in 3.8%. Approximately 75% had early stage diseases and 86% had endometrioid histology. We found 55.8% of EMC patients had other gynecologic lesions: 89.6% benign and 9.5% malignant. Some 4.5% had pre-invasive cervical/vulva/vagina lesions. The two most common gynecologic lesions were myoma uteri and ovarian tumors. Focusing on the latter, approximately 14% were benign while 8% were malignant. Among 364 patients with available data, surgical lesions were found in 11.8%, 5.7% benign and 9.2% malignant. The most common benign surgical condition was chronic appendicitis while breast and colon cancers were the two most common malignant lesions found. CONCLUSIONS: More than half of EMC patients had other gynecologic lesions including benign and malignant tumors. Surgical lesions were also found in more than one-tenth of patients. Careful pre-operative evaluation and intra-operative inspection are advised for proper management and better prognosis.

Synchronous and metachronous malignancy in endometrial cancer patients treated in a tertiary care center of Thailand.

OBJECTIVE: To evaluate the prevalence and features of non-endometrial cancers in Thai endometrial cancer (EC) patients. METHODS: EC patients treated in our institution were identified and the following data were collected: age, EC stage, histopathology, adjuvant therapy, other cancers, living status, and cause of death. RESULTS: The mean age of the 344 patients was 56.8 ± 10.8 years. Fifty (14.5%) had other synchronous and metachronous cancers. Mean ages of the patients with or without other cancers were not significantly different, 55.7 ± 10.04 years versus 57.1 ± 11.0 years, respectively (p=0.358). History of any cancer in the family and tumor in the lower uterine segment were more frequent among the patients with other cancers (6.0% vs. 1.7%, p=0.095; 12.0% vs. 1.0%, p<0.001; respectively). Six patients had ≥ 2 other cancers. Ovarian, breast, and colon were the three most common other cancers. After a median follow-up of 57.1 months, 18.3% of patients had died: 30.0% of patients with other cancers and 16.3% of those without other cancers. The corresponding EC deaths were 14.0% and 11.2%. The 5-year overall survival was significantly lower in patients who had other cancers: 79.3% (95% confidence interval [CI], 68.3 to 90.3) vs. 86.0% (95% CI, 81.7 to 90.3) than in those without (p=0.023). However, the corresponding disease-specific survival was not significantly different: 85.1% (95% CI, 75.5 to 94.7) compared with 89.0% (95% CI, 85.1 to 92.9), respectively (p=0.514). CONCLUSION: Thai EC patients had a high incidence of other cancers. Overall survival of EC patients who had other cancers was worse than those without, while disease-specific survival was not significantly different.

Patterns of adjuvant therapy for endometrial cancer: single institutional experience in Thailand.

AIM: The aim of this study was to evaluate the use of adjuvant therapy and treatment outcomes in patients with endometrial cancer (EMC). METHODS: Patients with EMC treated in the institution were identified. Data collected were age, stage of disease, histopathology, and adjuvant therapy. Progression-free survival (PFS) and overall survival (OS) were studied. RESULTS: The median age of 383 patients was 57 years (30-86 years). Majority had early-stage diseases (76.5%), endometrioid histopathology (87.2%), and high-grade tumors (74.9%). Less than half (44.4%) had adjuvant therapy. Pelvic radiation was the most common type of adjuvant treatment. We found that 25.7% of stages III to IV patients did not have adjuvant therapy (mainly from old age or poor performance status). On the other hand, 21.5% of patients with stage IA had adjuvant treatment (owing to risk factors or other synchronous cancers). The 5-year PFS and 5-year OS (95% confidence interval) were 84.3% (80.5%-88.1%) and 81.2% (77.1%-85.4%), respectively. Significant prognostic factors for survival by univariable analyses were stage, tumor grade, and histopathology. By multivariable analyses, significant prognostic factors were stage, tumor grade (only for OS), histopathology, and adjuvant therapy. Focusing on stage and adjuvant therapy, we found that the PFS and OS of early-stage patients who had or did not have adjuvant therapy were not significantly different, whereas the PFS and OS of advanced-stage patients who had adjuvant treatment were significantly higher than the PFS and OS of those who did not have adjuvant treatment. CONCLUSIONS: The use of adjuvant therapy for patients with EMC was not according to the standard recommendation in all patients for many reasons. The benefit of adjuvant therapy was demonstrated in advanced- but not in early-stage cancer.

Medical morbidities in endometrial cancer patients.

OBJECTIVES: The aim of this study was to evaluate the prevalence and types of medical morbidities in Thai endometrial cancer (EMC) patients and their impact on treatment outcomes. METHODS: The EMC patients treated in the institution from 1995 to 2012 and with available medical history were identified. Data collected were age; medical morbidities; tumor stage, histopathology, and grade; adjuvant therapy; living status; and cause of death. RESULTS: Of the 335 EMC patients included in the study, 77.3% had early-stage diseases, and 46.6% received adjuvant therapy. A total of 220 patients (65.7%) had medical morbidities. Median age of patients with medical morbidities was significantly higher than those without: 59 years (range, 30-84 years) versus 52 years (range, 30-86 years) (P < 0.001). One or more components of metabolic syndrome were the most common: 10.9% had all 4 components, 30.0% had three, and 31.4% had two. Thyroid dysfunction, as the second most common, was found in 8.2%. From a median follow-up of 56.5 months (0.07-234.04 months), 18.5% were dead: 11.6% from EMC, 4.8% from medical conditions, and 2.1% from other causes. Survival of the patients who had or had no medical morbidities was not significantly different: 5-year overall survival and 5-year cancer-specific survival were 84.7% (95% confidence interval [CI], 79.6%-89.8%) versus 84.0% (95% CI, 76.9%-91.0%) (P = 0.918) and 87.3% (95% CI, 82.6%-92.0%) versus 89.3% (95% CI, 83.2%-95.3%) (P = 0.986), respectively. CONCLUSION: This was the first large analysis in South-East Asia showing common incidence of medical morbidities in EMC patients. One or more components of metabolic syndrome were the most common. Some medical illnesses were the causes of death. Comprehensive and continual medical care for EMC patients is important.

Treatment outcomes of gemcitabine in refractory or recurrent epithelial ovarian cancer patients.

BACKGROUND: To study the response rate (RR), progression-free survival (PFS) and toxicity profiles of recurrent epithelial ovarian cancer (EOC) patients treated with gemcitabine. MATERIALS AND METHODS: Recurrent EOC patients who were treated with gemcitabine between January 2000 and December 2013 at the Department of Obstetrics and Gynecology, Faculty of Medicine Vajira Hospital were identified and medical records were reviewed. Clinico-pathological features including data of gemcitabine treatment, response and toxicity were collected. RESULTS: We identified 43 EOC patients who had gemcitabine treatment. All except one patient who did not receive any adjuvant treatment, had received platinum-based chemotherapy. Among these 42 patients, 31.0% had refractory cancer to first-line chemotherapy while 69.0% had recurrence with 48.8% being platinum- sensitive. The total cycles of gemcitabine used were 203 (median 4, range 2-9 cycles). Overall RR was 11.6%: 19% in platinum-sensitive vs 4.5% in platinum-resistant groups (p=0.158) and 42.9% in the patients having gemcitabine together with platinum vs 5.6% using gemcitabine alone (P=0.024). Median PFS was 3.6 months (95% confidence interval [CI], 2.73-4.49 months): 8.1 months (95% CI, 2.73-4.49 months) in combination regimen vs 3.2 months (95% CI, 2.01-4.42 months) in single regimen (p=0.077) and 8.1 months (95% CI, 4.73-11.48 months) with the gemcitabine combination vs 2.7 months (95% CI, 1.98-3.38 months) by single gemcitabine in platinum sensitive patients (P=0.007). Common toxicities were hematologic which were well tolerated and manageable. CONCLUSIONS: Gemcitabine has modest activity in pre-treated EOC. A combination regimen had higher activity than single agent in platinum sensitive patients with a significant improvement in RR and PFS.

Treatment outcomes of paclitaxel for refractory or recurrent epithelial ovarian cancer patients in Thailand.

BACKGROUND: To study the response rate, toxicity profiles, and survival of refractory or recurrent epithelial ovarian cancer (EOC) patients treated with paclitaxel. MATERIALS AND METHODS: Patients with refractory or recurrent EOC who were treated with paclitaxel between January 2002 and December 2011 at the Department of Obstetrics and Gynecology, Faculty of Medicine, Vajira Hospital were identified. Clinicopathological features of the patients including detailed data of paclitaxel treatment were collected. RESULTS: During the study period, a total of 44 patients were identified, with a mean age of 52.9±8.2 years. Some 13.6% (six patients) had refractory cancer to first-line chemotherapy while 86.4% (38 patients) had recurrent cancer. Among these, 35 (79.6%) and 9 (20.4%) patients were considered as platinum-sensitive and platinum-resistant, respectively. Three patients (6.8%) received fewer than 2 cycles of paclitaxel due to loss to follow-up, leaving 41 patients evaluable for response. The overall response rate observed in all 41 patients was 41.5% (17 patients; 12 complete and five partial responses): 12.5% or 1/8 patients with refractory or platinum-resistant cancer and 48.5% or 16/33 patients with platinum-sensitive disease. Stable disease was demonstrated in 17.0% (seven patients) while progressive disease was apparent in 41.5% (17 patients). Median time to progress was 4.5 months (range, 0.67- 58.6 months). Median progression-free survival was not reached while median overall survival was 16.3 months (95% confidence interval, 11.0 months -21.6 months). Common toxicities were neutropenia, neuropathy, and alopecia. CONCLUSIONS: Paclitaxel is an active agent for refractory or recurrent EOC. Neutropenia, neuropathy and alopecia are common side effects.

Endometrial carcinoma: clinical characteristic and survival rates by the new compared to the prior FIGO staging systems.

OBJECTIVE: To compare clinical characteristic features and survival rates of endometrial cancer (EMC) patients according to the new 2009 and prior 1988 FIGO staging systems. MATERIAL AND METHOD: Clinico-pathological data of EMC patients who had primary surgical treatment between 1992 and 2008 were collected. The new FIGO staging was compared to the prior assigned staging. Survivals of patients according to prior and new staging were compared RESULTS: Data from 259 patients was reviewed. Mean age was 55.4 +/- 9.9 years. Radiation was the most common adjuvant therapy after surgery, 95/106 patients (89.6%). Progression and recurrences occurred in 34 patients (16 with progression and 18 with recurrence) while 47 died (18.1%). Comparing the prior and current staging, early stage I-II was commonly found in both systems. Stages were the same in 81 patients (31.3%), lower in 177 (68.3%), and higher in one (0.4%). After a median follow-up of 57.5 months, 5-year progression-free, cancer-specific and overall survivals according to the prior and new systems were similar in stage III-IV. Survivals of new stage IA (from 16-prior stage IA, 124-IB, 12-IIA, and 1-IIIA) and stage IB (from 32-IC and 8-IIA) were worse than those of prior stage IA or IB. Survivals of the new stage II patients (11-IIB) were the same as prior stage IIB. CONCLUSION: The "new" FIGO staging system for endometrial cancer patients resulted in lower stage in a large number of patients. Survival trends were worse in the new stage I and remained similar in the other stages.

Expression of estrogen receptor, progesterone receptor, and Her-2/ neu in primary and extra-corporeal endometrial cancer.

OBJECTIVE: To compare immunohistochemical (IHC) expression of estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu in the primary tumors of endometrial cancer (EMC) and their extra-corporeal lesions. METHODS: Paraffin-embedded tissues of the primary and extra-corporeal tumors of EMC were retrieved for IHC study. Expression of ER, PR, and Her-2/ neu in the primary tumors and extra-corporeal lesions were compared. RESULTS: From 72 EMC patients with 87 extra-corporeal lesions, positive PR expression was significantly lower in the extra-corporeal lesions than that in the primary sites: 42.5% vs. 63.9%, respectively (p=0.007). No statistically significant differences of ER and Her-2/ neu expressions in the extra-corporeal and the primary sites were found: 42.5% and 55.6% for ER (p=0.102) and 20.7% vs. 13.9% for Her-2/ neu (p=0.262), respectively. The expression of extra-corporeal lesions were concordant to the primary tumor in 65.5% of ER (k=0.319), 71.2% of PR (k=0.445), and 83.9% of Her-2/ neu (k=0.413). From 15 cases wherein IHC from two extra-corporeal sites were studied, 73% had concordant ER expression between the two extra-corporeal lesions (k=0.412) while 93.3% had concordant PR and concordant Her-2/ neu expression (k=0.842 for PR and 0.634 for Her-2/ neu). CONCLUSION: PR expression was significantly higher in the primary tumors than the extra-corporeal sites. Higher ER and lower Her-2/ neu expressions in the primary tumors were also observed but the differences were not significant. The tumors heterogeneity suggests it may be important to study tumor tissues from both primary and extra-corporeal sites when planning treatment, especially by hormonal or targeted therapies.

Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer.

OBJECTIVE: To determine whether preoperative platelets to lymphocyte ratio (PLR) could predict disease stage, surgical outcome, and survival in patients with epithelial ovarian cancer (EOC). METHODS: Medical records of EOC patients who had surgery between January 2004 and December 2010 were reviewed. Clinicopathological and complete blood count data were collected. The optimal predictive value of PLR to predict advanced stage, suboptimal surgery, and survival was determined and compared with those of thrombocytosis (≥400,000 cells/mm(3)) and neutrophil to lymphocyte ratio (NLR) ≥2.6. RESULTS: A total of 166 EOC patients were included in the study. PLR of 200 yielded better predictive values than those of thrombocytosis and NLR ≥2.6. The area under curve (AUC), sensitivity, specificity, positive and negative predictive values, and accuracy of PLR to predict advanced stage were: 0.66, 59.0%, 72.7%, 65.7%, 66.7%, and 66.3%, respectively. The corresponding values to predict suboptimal surgery were: 0.70, 70.0%, 69.8%, 50.0%, 84.4%, and 69.9%. The patients who had PLR≥200 had significantly shorter progression-free and overall survivals than those with PLR<200. Stage, grade, surgical outcome, thrombocytosis, and PLR were significant prognostic factors for survivals by univariable analyses while only stage remained significant by multivariable analysis. CONCLUSION: PLR had potential clinical value in predicting advanced stage disease or suboptimal surgery. PLR was a better prognostic indicator for survivals of EOC patients compared to thrombocytosis or NLR>2.6.

Visual inspection with acetic acid for detection of high grade lesion in atypical squamous cells and low grade squamous intraepithelial lesions from cervical Pap smear.

OBJECTIVE: To evaluate the value of visual inspection with acetic acid (VIA) test to detect high grade lesion in women with atypical squamous cells or low grade squamous intraepithelial lesions cervical cytology. METHODS: Women with atypical squamous cells or low grade squamous intraepithelial lesions who were scheduled to undergo colposcopy at Vajira Hospital and met inclusion criteria were included. All participants underwent VIA test prior to usual steps of colposcopy. The VIA results were interpreted as positive or negative using the criteria by the International Agency for Cancer Research. The standard colposcopic examination and appropriate investigations for cervical pathology were then continued. The diagnostic values of VIA test including sensitivity, specificity, positive predictive value, and negative predictive value were determined using high grade lesion including cervical intraepithelial neoplasia 2-3 and squamous cell carcinoma as a threshold. RESULTS: Total of 106 women was included. The VIA test was positive in 33 women (31.1%) and negative in 73 women (68.9%). Among the women with VIA test positive, 14 had high grade lesion (42.4%) while 19 had no significant lesions. Only 2/73 (2.7%) cases with negative VIA test had high grade lesion (both had cervical intraepithelial neoplasia 2). The sensitivity, specificity, positive predictive value and negative predictive value with 95% confidence interval were 87.5% (81.2 to 93.8%), 78.8% (71.1 to 86.7%), 42.4% (33.0 to 51.8%), and 97.2% (94.2 to 1.0%) respectively. CONCLUSION: VIA as the intermediate test in atypical squamous cells and low grade squamous intraepithelial lesions cytology may reduce the necessity to refer some women for colposcopy.

Expression of ER, PR, and Her-2/neu in endometrial cancer: a clinicopathological study.

OBJECTIVE: To determine any association between expression of estrogen receptor (ER), progesterone receptor (PR), and Her-2/neu and clinicopathological features, including survival, of endometrial carcinoma (EMC) patients. METHODS: Samples of formalin-fixed, paraffin-embedded tissue of 108 patients with EMC treated at our institution between January 1994 and December 2007 were immunohistochemically studied. RESULTS: ER, PR, and Her-2/neu expression were positive in 59.3%, 65.7% and 2.8% of cases, respectively. Positive ER expression was significantly associated with grade I-II tumor while PR expression was linked with endometrioid histology, grade I-II tumor, less myometrial invasion (MI) and negative lymph node involvement. Her-2/neu expression was significantly associated with deep MI, while positive ER and negative Her-2/neu expression in combination was significantly associated with longer disease-free and overall survival. CONCLUSION: ER expression is a good prognostic factor while Her-2/neu expression appears to be a poor indicator for both disease-free and overall survival, while PR tended to show favorable influence for only disease-free survival of Thai EMCs.

Clinicopathological features including hormonal receptor expression and survival in young endometrial cancer patients: a case control study.

OBJECTIVE: To compare clinicopathological features, including hormonal receptor expression and survival, in young Thai endometrial carcinoma (EMC) patients with older patients. METHODS: Young EMC patients aged ≤45 years, treated in the institution from 1992 to 2008, were identified as cases. Controls included EMC patients aged >45 years who had an operation on the nearest dates to the cases. Clinicopathological data and survival of the cases and controls were compared. RESULTS: Mean ages of 41 cases and 123 controls were 40.4 ± 3.7 years and 58.4 ± 8.3 years, respectively. Cases were significantly different from controls in terms of having more nulliparity (58% vs 25%), less medical illness (57% vs 79%), more low-grade tumors (49% vs 14%), more positive estrogen (78% vs 56%) and progesterone (97% vs 61%) receptors expression, and fewer nodal metastases (3% vs 21%). Adjuvant therapy was administered in 29% of the cases and 46% of the controls. From a median follow up of 51 months, cases had significantly fewer progression events and recurrence (5% vs 19%), cancer-related deaths (2% vs 16%), and all deaths (5% vs 23%), with significantly longer 5-year disease-free (97.2% vs 79.6%, p=0.023), cancer-specific (97.1% vs 83.2%, p=0.020), and overall survival (93.1% vs 78.8% p=0.005) than controls as determined by univariate analysis. Survival of cases and controls were not significantly different after adjusting for other prognostic factors. CONCLUSION: Young Thai EMC patients had more favorable clinicopathological features with significantly longer survival than older patients as determined by univariate analysis.

Endometrial cancer in Thai women: clinico-pathological presentation and survival.

OBJECTIVE: To assess the characteristic features, treatment, survival, and prognostic factors of Thai endometrial cancer (EMC) patients. METHODS: Clinico-pathological data of EMC patients who were treated in the institution from 1992 to 2008 were collected. Survival rates and prognostic factors were studied. RESULTS: The mean age of the 261 patients was 55.4 ± 9.92 years. The most common complaint was abnormal uterine bleeding (87.3%). More than half (75.4%) had other medical illnesses or other cancers (10.7%). The majority (78%) had early stage disease. Post-operative adjuvant therapy was given in 41.4%; the most common was radiation therapy (37.2%). From a median follow-up of 57.5 months (range 0.03-212.3 months), progressive disease was encountered in 16 patients. Eighteen experienced recurrence (three local, 13 distant metastases and two local and distant). Overall, 30 patients died of cancer, while 18 died of other medical illnesses. The 5-year progression-free, cancer specific, and overall survivals (95% confidence intervals) were 86.5% (82.1-90.8%), 88.0% (83.9-92.2%), and 83.6% (78.7-88.4%), respectively. Significant prognostic factors for survival were: histology, grade, depth of myometrial invasion, cervical involvement, lymphovascular invasion, lymph node status, and Her-2/ neu expression. CONCLUSION: Most endometrial cancer patients in Thailand present at early stages and experience good survival outcomes.